Recognition of abuse

Concept of significant harm

Some children are in need because they are suffering, or likely to suffer, significant harm. The Children Act 1989 introduced the concept of significant harm as the threshold that justifies compulsory intervention in family life in the best interests of children, and gives local authorities a duty to make enquiries to decide whether they should take action to safeguard or promote the welfare of a child who is suffering, or likely to suffer, significant harm.

There are no absolute criteria on which to rely when judging what constitutes significant harm. Consideration of the severity of ill-treatment may include the degree and the extent of physical harm, the duration and frequency of abuse and neglect, the extent of premeditation, and the presence or degree of threat, coercion, sadism and bizarre or unusual elements.

Each of these elements has been associated with more severe effects on the child, and / or relatively greater difficulty in helping the child overcome the adverse impact of the maltreatment.

Sometimes, a single traumatic event may constitute significant harm (e.g. a violent assault, suffocation or poisoning). More often, significant harm is a compilation of significant events, both acute and longstanding, which interrupt, change or damage the child’s physical and psychological development.

Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long-term neglect, emotional, physical or sexual abuse that causes impairment to the extent of constituting significant harm.

Definitions of child abuse and neglect

Physical abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent fabricates the symptoms of, or deliberately induces, illness in a child.

Emotional abuse

Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent effects on the child’s emotional development, and may involve:

Conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person;

Imposing age or developmentally inappropriate expectations on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction;

Seeing or hearing the ill-treatment of another;

Serious bullying, causing children frequently to feel frightened or in danger, or the exploitation or corruption of children;

Exploiting and corrupting children.

Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

Sexual abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts.

Sexual abuse includes abuse of children through sexual exploitation. Penetrative sex where one of the partners is under the age of 16 is illegal, although prosecution of similar age, consenting partners is not usual. However, where a child is under the age of 13 it is classified as rape under s5 Sexual Offences Act 2003.

Sexual abuse includes non-contact activities, such as involving children in looking at, or in the production of pornographic materials, watching sexual activities or encouraging children to behave in sexually inappropriate ways.

Neglect

Neglect is the persistent failure to meet a child’s basic physical and / or psychological needs, likely to result in the serious impairment of the child’s health or development.

Neglect may occur during pregnancy as a result of maternal substance abuse.

Once a child is born, neglect may involve a parent failing to:

Provide adequate food, clothing and shelter (including exclusion from home or abandonment);

Protect a child from physical and emotional harm or danger;

Ensure adequate supervision (including the use of inadequate care-givers);

Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

Recognition of abuse and neglect

The factors described below are frequently found in cases of child abuse or neglect. Their presence is not proof that abuse has occurred, but:

Must be regarded as indicators of the possibility of significant harm;

Indicates a need for careful assessment and discussion with the agency’s nominated child protection person;

May require consultation with and/or referral to the LA children’s social care and / or the police.

The absence of such indicators does not mean that abuse or neglect has not occurred.

Frequently complain about / to the child and may fail to provide attention or praise (high criticism / low warmth environment);

Be absent or leave the child with inappropriate carers;

Have mental health problems which they do not appear to be managing;

Be misusing substances;

Persistently refuse to allow access on home visits;

Persistently avoid contact with services or delay the start or continuation of treatment;

Be involved in domestic violence;

Fail to ensure the child receives an appropriate education.

Professionals should be aware of the potential risk of harm to children when individuals (adults or children), previously known or suspected to have abused children, move into the household.

Recognising physical abuse

The following are often regarded as indicators of concern:

An explanation which is inconsistent with an injury;

Several different explanations provided for an injury;

Unexplained delay in seeking treatment;

The parent/s are uninterested or undisturbed by an accident or injury;

Parents are absent without good reason when their child is presented for treatment;

Repeated presentation of minor injuries (which may represent a ‘cry for help’ and if ignored could lead to a more serious injury);

Frequent use of different doctors and accident and emergency departments;

Reluctance to give information or mention previous injuries.

Bruising

Children can have accidental bruising, but the following must be considered as indicators of harm unless there is evidence or an adequate explanation provided. Only a paediatric view around such explanations will be sufficient to dispel concerns listed below:

Any bruising to a pre-crawling or pre-walking baby;

Bruising in or around the mouth, particularly in small babies which may indicate force feeding;

Two simultaneous bruised eyes, without bruising to the forehead, (rarely accidental, though a single bruised eye can be accidental or abusive);

Repeated or multiple bruising on the head or on sites unlikely to be injured accidentally;

Variation in colour possibly indicating injuries caused at different times;

The outline of an object used (e.g. belt marks, hand prints or a hair brush);

Bruising or tears around, or behind, the earlobe/s indicating injury by pulling or twisting;

Bruising around the face;

Grasp marks on small children;

Bruising on the arms, buttocks and thighs may be an indicator of sexual abuse.

Bruising is strongly related to mobility:

Once children are mobile they sustain bruises from everyday activities and accidents;

Bruising in a baby who is not yet crawling, and therefore has no independent mobility, is very unusual;

Only one in five infants who is starting to walk by holding on to the furniture has bruises. Infants who are pulling to stand may bump and bruise their heads, usually the forehead;

Most children who are able to walk independently have bruises;

Bruises usually happen when children fall over or bump into objects in their way;

Children have more bruises during the summer months;

The shins and the knees are the most likely places where children who are walking, or starting to walk, get bruised;

Most accidental bruises are seen over bony parts of the body, e.g. knees and elbows, and are often seen on the front of the body;

Fractures are not always accompanied by bruises.

There are some patterns of bruising that may mean physical abuse has taken place, including:

Abusive bruises often occur on soft parts of the body, e.g. cheeks, abdomen, back and buttocks;

The head is by far the commonest site of bruising in child abuse;

Clusters of bruises are a common feature in abused children. These are often on the upper arm, outside of the thigh, or on the body;

As a result of defending themselves, abused children may have bruising on the forearm, face, ears, abdomen, hip, upper arm, back of the leg, hands or feet;

Abusive bruises can often carry the imprint of the implement used or the hand;

Non-accidental head injury or fractures can occur without bruising.

It is not possible to accurately ‘age’ a bruise. Estimates of the age of a bruise are currently based on an assessment of the colour of the bruise with the naked eye. The accuracy of observers who estimate the age of a bruise visually is no better than 50 per cent. The evidence is that it is not possible to accurately age a bruise from an assessment of colour – from either a clinical assessment or a photograph. A practitioner who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so from their own experience without adequate published evidence. A bruise should never be interpreted in isolation and must always be assessed in the context of the child’s medical and social history, developmental stage and explanation given.

It should also be noted that there is a condition called ‘Mongolian Blue Spot’ which can look like bruising but is not bruising. This condition is common among darker-skinned children, particularly those of Asian, East Indian and African descent. The ‘spots’ are flat, pigmented lesions with unclear borders and irregular shape. They appear commonly at the base of the spine, on the buttocks and back. They may also appear as high as the shoulders and elsewhere. They are not associated with any illness or abuse. It would require paediatric assessment to confirm that such a condition was present in a child about whom apparent bruising was thought to be indicative of physical abuse.

Bite marks

Bite marks can leave clear impressions of the teeth. Human bite marks are oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.

A medical opinion should be sought where there is any doubt over the origin of the bite.

Bites are a relatively common injury in children. Approximately 1 per cent of all Accident and Emergency attendances are due to bites, and around one in 600 children attending A & E have been bitten. When an adult bites a child sufficiently hard to leave a mark, it is an assault. An adult bite on a child is the only physical injury where there is the potential to identify exactly who has attacked the child.

A bite leaves an oval or circular mark, consisting of two symmetrical, opposing, u-shaped arches separated at their base by an open space. The arcs may include puncture wounds, indentations or bruising from the marks of individual teeth. These marks are what make bites unique.

Oral injuries

Dogs and other carnivores, e.g. ferrets or rats, tend to tear the skin and leave deep puncture wounds. These are also much narrower bites than human ones.

Children often bite one another and they may also be bitten by animals. The challenge, therefore, is to recognise when an injury is a human bite and whether caused by an adult.

Burns and scalds

It can be difficult to distinguish between accidental and non- accidental burns and scalds, and will always require experienced medical opinion. Any burn with a clear outline may be suspicious.

It can be difficult to distinguish between accidental or non accidental burns and scalds and this will always require experienced medical opinion.

Any burn with a clear outline should be investigated, such as:

Circular burns which may be caused by burns from cigarettes (but these may be friction burn if along the bony protuberance of the spine);

Linear burns which may be burns from hot metal rods or electrical fire elements;

Marks which indicate a burn from an iron;

Burns of uniform depth over a large area;

Scalds that have a line, such as those caused by immersion in hot water, for example ‘sock’ or ‘glove’ scalds (a child getting into hot water of his/her own accord will struggle to get out and cause uneven splash marks);

Old scars indicating previous burns / scalds which did not have appropriate treatment or adequate explanation.

Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint, and loss of function in the limb or joint.

Non-mobile children rarely sustain fractures.

There are grounds for concern if:

The history provided is vague, non-existent or inconsistent with the fracture type;

There are associated old fractures;

Medical attention is sought after a period of delay when the fracture has caused symptoms such as swelling, pain or loss of movement;

There is an unexplained fracture in the first year of life.

Fractures are a normal part of growing up, with up to 66 per cent of boys and around 40 per cent of girls sustaining a fracture by their 15th birthday. 85 per cent of accidental fractures are seen in children over five years of age. However, they can also be indicative of a serious assault on a child.

Fractures occur in up to 25 per cent of physically abused children;

80 per cent of these fractures are in children under 18 months;

Any bone in the body can be broken as a result of child abuse;

Many abusive fractures are not clinically obvious unless x-rays are taken, especially in infants under two years;

Fractures, particularly rib fractures, may not be accompanied by bruising;

Fractures in very young children may present with non-specific symptoms and may only be revealed by x-ray or other radiological tests;

Fractures may not be obvious even on x-ray immediately after the injury and they are easier to identify once the bones show some signs of healing;

Abused children frequently have multiple fractures and these may be of different ages.

Although a recent fracture can be distinguished from an old fracture radiologists can estimate the age only in weeks, not days. Despite fractures showing predictable x-ray features over time as they heal, dating of fractures in abused children can be difficult if:

No accurate description of the cause or timing of the injury has been given;

Further injury to an already broken bone occurs;

The bone has not been immobilised, which may alter the rate of healing.

Mouth and Teeth Injuries

The following must be taken into account when dealing with a child who has mouth injuries.

Up to 50 per cent of children sustain an injury to the mouth by the time they leave school. Most of these are accidental and, in older children, often caused by falls and sporting accidents.

In cases of physical abuse, the head and face are the areas of the body most commonly injured. Injuries to the lips are the commonest recorded abusive injury to the mouth. These are either cuts or bruises. However, all areas of the mouth can be injured in physical abuse, for example, teeth may be displaced or broken and there may be cuts, abrasions or bruises to the inside of the lips, the roof of the mouth, the tongue or the lingual frenulum (underneath the tongue). Injuries to the mouth, including the teeth, can cause considerable pain and discomfort and, if left untreated, may well affect a child’s appetite and growth.

It is very difficult to tell if there has been an injury to the mouth. However, a child may complain of a pain in their mouth or have difficulty eating, or the teeth may be discoloured (brown or grey), which may mean that there is an old injury. A broken tooth may be recognised only because of a subtle grey discolouration. Abusive injuries to the mouth are not always obvious and, unless a child discloses abuse, will come to light only if it is noticed that permanent teeth are inexplicably missing.

It has been thought for some time that a torn frenum was diagnostic of physical abuse. A frenum (often also called a frenulum) is the fold of tissue inside the mouth that joins the upper or lower lip to the gums. In the scientific literature there are 28 recorded cases. The vast majority of these children suffered from multiple injuries and died from the assault. Most were under five years old.

A torn frenum can also occur accidentally if a toddler or young child falls on their face, catches their mouth on low-level furniture or receives an accidental blow to the face, e.g. by a swing. There is not enough evidence in the literature to support the view that a torn frenum in isolation is diagnostic of child abuse. Any injury of this type must be assessed in the context of the explanation given, the child’s developmental stage, a full examination and other relevant investigations as appropriate.

Scars

A large number of scars or scars of different sizes or ages, or on different parts of the body, may suggest abuse.

Recognising emotional abuse

Emotional abuse may be difficult to recognise, as the signs are usually behavioural rather than physical.

The indicators of emotional abuse are often also associated with other forms of abuse. Professionals should therefore be aware that emotional abuse might also indicate the presence of other kinds of abuse.

The following may be indicators of emotional abuse:

Developmental delay;

Abnormal attachment between a child and parent (e.g. anxious, indiscriminate or no attachment);

Indiscriminate attachment or failure to attach;

Aggressive behaviour towards others;

Appeasing behaviour towards others;

Scapegoated within the family;

Frozen watchfulness, particularly in pre-school children;

Low self esteem and lack of confidence;

Withdrawn or seen as a ‘loner’ – difficulty relating to others.

There is increasing evidence of the adverse long-term consequences for children's development where they have been subject to sustained emotional abuse. Emotional abuse has an important impact on a developing child's mental health, behaviour and self-esteem. It can be especially damaging in infancy.

Underlying emotional abuse may be as important, if not more so, than other more visible forms of abuse in terms of its impact on the child. Domestic violence, adult mental health problems and parental substance misuse may be features in families where children are exposed to such abuse.

Alopecia

Hair loss (alopecia) in a child can be for organic or non-organic reasons. Hair loss in a child may also be due to stress directly linked to maltreatment. Hair loss may also occur in a child as a result of pulling the child’s hair.

Bullying

Bullying is emotionally abusive as well as taking other forms. When working with a child and family, practitioners should take into account the possibility that a child may be the victim of bullying.

Bullying may be defined as deliberately hurtful behaviour, usually repeated over a period of time, where it is difficult for those bullied to defend themselves. It can take many forms, but the four main types are:

Physical (e.g. hitting, kicking, theft);

Verbal (e.g. racist or homophobic remarks, threats, name-calling);

Emotional (e.g. isolating an individual from the activities and social acceptance of their peer group);

Cyber bullying ( use of new technologies by children and young people to intimidate peers, and sometimes those working with them e.g., teachers)

The damage inflicted by bullying can frequently be underestimated. It can cause considerable distress to children, to the extent that it affects their health and development or, at the extreme, causes them significant harm (including self-harm).

Practitioners should be aware of signs that a child is frightened or intimidated by his/her peers or older children/adults and should work in partnership with parents/carers and colleagues to address both the bullying behaviour and the impact of bullying on the victim.

Recognising sexual abuse

Sexual abuse can be very difficult to recognise and reporting sexual abuse can be an extremely traumatic experience for a child. Therefore both identification and disclosure rates are deceptively low.

Boys and girls of all ages may be sexually abused. Many are frequently scared to say anything due to guilt and / or fear. According to a recent study, three-quarters (72%) of sexually abused children did not tell anyone about the abuse at the time. Twenty-seven percent of the children told someone later, and around a third (31%) still had not told anyone about their experience/s by early adulthood*.

If a child makes an allegation of sexual abuse, it is very important that they are taken seriously. Allegations can often initially be indirect as the child tests the professional’s response. There may be no physical signs and indications are likely to be emotional / behavioural.

Involvement in sexual exploitation or indiscriminate choice of sexual partners;

An anxious unwillingness to remove clothes for e.g. sports events (but this may be related to cultural norms or physical difficulties).

Physical indicators associated with child sexual abuse include:

Pain or itching of genital area;

Blood on underclothes;

Pregnancy in a child;

Physical symptoms such as injuries to the genital or anal area, bruising to buttocks, abdomen and thighs, sexually transmitted disease, presence of semen on vagina, anus, external genitalia or clothing.

Sex offenders have no common profile, and it is important for professionals to avoid attaching any significance to stereotypes around their background or behaviour. While media interest often focuses on ‘stranger danger’, research indicates that as much as 80 per cent of sexual offending occurs in the context of a known relationship, either family, acquaintance or colleague.

Recognising neglect

It is rare that an isolated incident will lead to agencies becoming involved with a neglectful family. Evidence of neglect is built up over a period of time. Professionals should therefore compile a chronology and discuss concerns with any other agencies which may be involved with the family, to establish whether seemingly minor incidents are in fact part of a wider pattern of neglectful parenting.

When working in areas where poverty and deprivation are commonplace professionals may become desensitised to some of the indicators of neglect. These include:

Disabled children and young people can be particularly vulnerable to neglect due to the increased level of care they may require.

Although neglect can be perpetrated consciously as an abusive act by a parent, it is rarely an act of deliberate cruelty. Neglect is usually defined as an omission of care by the child’s parent, often due to one or more unmet needs of their own. These could include domestic violence, mental health issues, learning disabilities, substance misuse, or social isolation / exclusion, this list is not exhaustive.

While offering support and services to these parents, it is crucial that professionals maintain a clear focus on the needs of the child.